09-06-18 Latest and Greatest in ARDS Treatment
Drs. Yau, Tenure and Kiamanesh
6:00 PM @ Curry Club, 10 Woods Corner Rd, Setauket- East Setauket
• Guérin C et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013 Jun 6;368(23):2159-6 [PubMed]
• Combes A et al. Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome . N Engl J Med. 2018 May 24;378(21):1965-1975 [PubMed]
...Dr Tenure gave a concise review of the Combes et al article. This was a randomized trial that compared ARDS patients given ECMO with those given standard mechanical ventilation and ECMO for rescue. Continuous ECMO did not lower the 60 day mortality significantly. Pulmonologist Dr. Paul Richman noted that that physicians who are very pro ECMO thought that the study was stopped too early. Extending the study timeframe and recruitment of more patients, might have revealed a significant benefit to ECMO.
Dr. Yau gave an excellent review on the Guérin C et al. article. This prospective, multicenter, randomized controlled trial of 466 patients in France and Spain, explored whether prone positions improved survival among patients who received mechanical ventilation with PEEP (5 cm H2O) and in who the partial pressure arterial oxygen to fraction of inspired oxygen was less than 150 mmHg. The researchers found that early prone position sessions decreased both 28 day and 90 day mortality. Dr Paul Richman noted that, although rotoprone beds can be ordered if needed, it is not necessary to use them. The same results can be obtained by manual turn/flip of the patient ( similar to what we do in the OR for prone cases.) It was also noted that the low body habitus of Europeans makes for easier access to the abdomen. All that might be necessary is placement of a blanket under the shoulders and hips. This option is less useful in the US patient population where the BMI is much higher overall.
10-18-18 Issues in Pre-Op Assessments
Drs. Wetcher, Mouch, Richman, Makaryus
6:00 PM @ HSC Galleria
• Wijeysundera et al. Assessment of functional capacity before major non-cardiac surgery: an international, prospective cohort study. Lancet. 2018 Jun 30;391(10140):2631-2640. [PubMed]
• Glance et al. Impact of the Choice of Risk Model for Identifying Low-risk Patients Using the 2014 American College of Cardiology/American Heart Association Perioperative Guidelines. Anesthesiology. 2018 Nov;129(5):889-900 [PubMed]
Dr. Wetcher gave a terrific review of the Wijeysundera et al article. He clearly explained the assessment tools of CPET (cardiopulmonary exercise testing), DASI (Duke Activity Status Index), the blood test NT pro-BNP, and METS. This multi-center prospective cohort found that subjective assessment of functional capacity should not be used in clinical practice. It was suggested from the study that clinicians should use the DASi questionnaire and NT pr BNP testing to assess perioperative cardiac risk and CPET possibly to predict complications after major elective noncardiac surgery. It was discussed that what is done in our preoperative testing at SB is more precise on elaboration of specifics with activity. Subjective questions are advantageous here.
Dr. Mouch gave a concise review of the Glance et al. article. He explained the risk calculators based on (NSQIP) National Surgical Quality Improvement and (RCRI) Revised Cardiac Risk Index. These can be used to assess the risk of cardiac adverse events after noncardiac surgery. Agreement across these calculators is poorly understood. The article showed that there is a wide variability in the predicted risk of cardiac complications using different risk -prediction tools. In addition, inclusion of more that one prediction tool in clinical guidelines could lead to different decision-making for some patients. The mapping of NSQIP data to RCRI risk factors is not perfect. This could lead to less accurate RCRI predictions. Interestingly, the age of a patient and ASA status have withstood the test of time as a good predictors. It is better to use the info for prevention instead of talking about the failure to rescue. Of course, all of these issues should ideally be addressed 6 months before the patient comes for surgery.
Drs. Al Bizri, Mcmanus
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